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Intestinal occlusion caused by endometriosis of the sigmoid colon A case report and review of the literature Published online 21 Dicembre 2011 (www.annitalchir.com) - Ann. Ital. Chir., 83, 4, 2012 353 Introduction Endometriosis (E), an estrogen-dependent inflammatory disorder in which endometrial tissue develops outside uterus, is found in approximately 10% of women in childbearing age and in 15-20% of cases is associated with sterility. There is intestinal involvement, especially of the sigmoid colon and rectum, in about 5% of patients 1 . The dif- Pervenuto in Redazione Luglio 2011. Accettato per la pubblicazione Novembre 2011 Correspondence to: Giovanni Conzo, MD, Aggregate Professor of General Surgery, VII Division of General Surgery, Dipartimento di scienze Anestesiologiche, Chirurgiche e dell’Emergenza, Second University of Naples, Via Pansini 5, Ed. 17- 80131 Naples, Italy (e-mail: giovan- [email protected]). Giovanni Conzo, Giovanni Docimo, Giancarlo Candela, Antonietta Palazzo, Cristina Della Pietra, Claudio Mauriello, Luigi Santini VII Divisione di Chirurgia Generale, Dipartimento di Scienze Anestesiologiche, Chirurgiche e dell’Emergenza, Seconda Università degli Studi di Napoli, Italia Intestinal occlusion caused by endometriosis of the sigmoid colon. A case report and review of the literature Endometriosis (E) is an estrogen-dependent inflammatory disorder that is observed in approximately 10% of women in childbearing age, and is the most common benign gynecological disorder requiring hospitalization. In 5% of cases, there is an involvement of the gastrointestinal tract, for the most part of the sigmoid colon and rectum (~ 90%). However intestinal obstruction due to severe stenosis of the sigmoid colon, as in the case described by the authors, is rare. The differential diagnosis should include cancer, inflammatory diseases and actinic colitis which has a similar clinical picture to E. Surgical treatment - resection and anastomosis or conservative procedures - provides better results especially when a multidisciplinary approach is used (colorectal surgeon, gynecologist, urologist). The authors report a case of obstruction of the sigmoid colon due to endometriosis and analyze the pathophysiology, diag- nosis and surgical management of this disorder. KEY WORDS: Endometriosis, Intestinal occlusion, Rectal anterior resection, Stapled anastomosis. ferential diagnosis of rectosigmoid E can be complex since it includes conditions like diverticulitis, Crohn’s dis- ease, actinic colitis and cancer, all of which can cause similar signs &symptoms 2 . The authors report a case of intestinal endometriosis in which the clinical picture and imaging suggested a diag- nosis of intestinal occlusion due to sigmoid colon can- cer, with indication to emergency colorectal resection. Case report In March, 2008, a 42-year-old woman came to our obser- vation complaining of abdominal pain in the left lower quadrant, associated with episodes of rectal bleeding and constipation, that had begun one month earlier. The patient had a history of chronic hepatitis C, and arterial hypertension managed by pharmacological ther- apy. At age 38 she had undergone total hysterectomy plus Ann. Ital. Chir., 2012 83: 353-356 Published online 21 Dicembre 2011 (www.annitalchir.com)

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Page 1: Intestinal occlusion caused by endometriosis of the ... · of the sigmoid colon ... Rectal anterior resection, Stapled anastomosis. ... undergone laparoscopic cholecystectomy for

Intestinal occlusion caused by endometriosisof the sigmoid colonA case report and review of the literature

Published online 21 Dicembre 2011 (www.annitalchir.com) - Ann. Ital. Chir., 83, 4, 2012 353

Introduction

Endometriosis (E), an estrogen-dependent inflammatorydisorder in which endometrial tissue develops outsideuterus, is found in approximately 10% of women inchildbearing age and in 15-20% of cases is associatedwith sterility.There is intestinal involvement, especially of the sigmoidcolon and rectum, in about 5% of patients 1. The dif-

Pervenuto in Redazione Luglio 2011. Accettato per la pubblicazioneNovembre 2011Correspondence to: Giovanni Conzo, MD, Aggregate Professor of GeneralSurgery, VII Division of General Surgery, Dipartimento di scienzeAnestesiologiche, Chirurgiche e dell’Emergenza, Second University ofNaples, Via Pansini 5, Ed. 17- 80131 Naples, Italy (e-mail: [email protected]).

Giovanni Conzo, Giovanni Docimo, Giancarlo Candela, Antonietta Palazzo, Cristina Della Pietra, Claudio Mauriello, Luigi Santini

VII Divisione di Chirurgia Generale, Dipartimento di Scienze Anestesiologiche, Chirurgiche e dell’Emergenza, Seconda Università degliStudi di Napoli, Italia

Intestinal occlusion caused by endometriosis of the sigmoid colon. A case report and review of the literature

Endometriosis (E) is an estrogen-dependent inflammatory disorder that is observed in approximately 10% of women inchildbearing age, and is the most common benign gynecological disorder requiring hospitalization. In 5% of cases, thereis an involvement of the gastrointestinal tract, for the most part of the sigmoid colon and rectum (~ 90%). However intestinal obstruction due to severe stenosis of the sigmoid colon, as in the case described by theauthors, is rare. The differential diagnosis should include cancer, inflammatory diseases and actinic colitis which has asimilar clinical picture to E. Surgical treatment - resection and anastomosis or conservative procedures - provides betterresults especially when a multidisciplinary approach is used (colorectal surgeon, gynecologist, urologist).The authors report a case of obstruction of the sigmoid colon due to endometriosis and analyze the pathophysiology, diag-nosis and surgical management of this disorder.

KEY WORDS: Endometriosis, Intestinal occlusion, Rectal anterior resection, Stapled anastomosis.

ferential diagnosis of rectosigmoid E can be complexsince it includes conditions like diverticulitis, Crohn’s dis-ease, actinic colitis and cancer, all of which can causesimilar signs &symptoms 2. The authors report a case of intestinal endometriosis inwhich the clinical picture and imaging suggested a diag-nosis of intestinal occlusion due to sigmoid colon can-cer, with indication to emergency colorectal resection.

Case report

In March, 2008, a 42-year-old woman came to our obser-vation complaining of abdominal pain in the left lowerquadrant, associated with episodes of rectal bleeding andconstipation, that had begun one month earlier. The patient had a history of chronic hepatitis C, andarterial hypertension managed by pharmacological ther-apy. At age 38 she had undergone total hysterectomy plus

Ann. Ital. Chir., 2012 83: 353-356Published online 21 Dicembre 2011

(www.annitalchir.com)

Page 2: Intestinal occlusion caused by endometriosis of the ... · of the sigmoid colon ... Rectal anterior resection, Stapled anastomosis. ... undergone laparoscopic cholecystectomy for

right oophorectomy for metrorrhagia due to chronic cer-vicitis and endocervical micropolyps. At age 40 she hadundergone laparoscopic cholecystectomy for recurrent bil-iary colic due to cholelithiasis. A pancolonoscopy, that hadbeen performed in another institution, showed an infil-trating lesion of the distal sigmoid colon, approximately25 cm from the anal verge, bleeding, causing circumfer-ential stenosis of the lumen. Biopsy results were incon-clusive. Routine blood tests and tumor marker levels (CA50, CEA, CA 19-9, CA 125) were normal except for theTPA level which was 74 UI/ml, slightly above normal. An abdominopelvic computed tomography (CT) scanwith contrast agent revealed thickening of the colon wallat the rectosigmoid junction. There was no pelvic orabdominal lymphadenopathy.Emergency surgery was performed because of patient’sworsening clinical condition (repeated episodes of rectalbleeding and severe abdominal distension). After lysis of several adhesions resulting from the prior

hysterectomy, the patient underwent open anterior resec-tion of the sigmoid colon with stapled colorectal anas-tomosis along with left oophorectomy. The patient’s post-operative course was uneventful and she was dischargedon postoperative day 9.The definitive histological examination showed “florid, dif-fuse sigmoid colon endometriosis involving the entirethickness of the wall with hyperplasia of the muscularcomponent which surrounds nests of endometriosis; fol-licular and corpus luteum cysts in the ovary” (Fig. 1).

Discussion

Endometriosis, defined as the presence of endometrial tis-sue outside the uterus, is not easy to diagnose or treat.The complexity of the clinical presentation of E oftendemands the collaboration of a multidisciplinary team con-sisting of a gynaecologist, coloproctologist and urologist.

G. Conzo, et. al.

354 Ann. Ital. Chir., 83, 4, 2012 - Published online 21 Dicembre 2011 (www.annitalchir.com)

Fig. 1: Optical Microscopy. A) Hyperplastic endometrial glands whose lumen is slightly dilatated.Note the epithelial pluristratification and the edematous stroma E-E 20x.B) Paraffin embedded endometrial section showing a few glands. Notethe different gland sizes. Stroma is fibrotic and shows periglandularinflammation.E-E 4x.C) Hypercellular stroma with glands. The typical features of cytogenendometrial like stroma are readily evident E-E 10x.

A B

C

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Endometriosis is an estrogen-dependent inflammatorydisease which affects 10% of women in childbearing ageand is the most common benign gynaecologic conditionrequiring hospitalization1. The prevalence of E rangesfrom 1% to 20% in asymptomatic women and is 60-70% in women with chronic pelvic pain. Frequently thedisease is not associated with any specific symptom.Hormonal stimulation of the endometrial implantsresults in cyclical bleeding associated with irritation andscarring of surrounding tissue which sometimes involvesneighbour structures, causing specific symptoms. Theovaries are most often involved, followed by Douglas’pouch, the rectovaginal septum, and the rectum.Extrapelvic E can occur almost anywhere in the body,including bowel, urinary tract, muscles, liver, gallbladder,and heart. Ninety-five percent of cases involve sigmoidcolon and rectum 3,4. The mean age of women diagnosed with E was between34 and 40 years, and 7% of them were found to be inpostmenopausal period5. The incidence of intestinal Eranges from 5.3% to 12%, and in 90% of cases the sig-moid colon and rectum are involved.In the rare cases in which the disease affects small bow-el, it is most often found in the distal ileum (1% ofcases)6,7,and usually involves the serosa. Intestinal E presents with abdominal pain, commonly inthe left lower quadrant, dyschezia, abdominal distention,and rectal bleeding, a clinical presentation similar to thatof diverticulitis, Crohn’s disease, and rectal cancer 8-9.Since the mucosal layer is rarely involved, occlusion ofthe lumen of the colon/rectum hardly occurs 9. It is not easy to diagnose intestinal E based on symp-toms alone since there are many, often misleading mani-festations of the disease 10.Endoscopic diagnosis of intestinal E is sometimes diffi-cult and colonoscopy is negative due to the absence ofmucosal infiltration. When the mucosa is affected, theresults of endoscopy are similar to those obtained in cas-es of chronic inflammatory diseases of bowel, ischemiccolitis, actinic colitis and neoplasia. Since the colonicmucosa is not involved, endometrial implants may havethe characteristics of an extrinsic lesion. Virtualcolonoscopy does not seem to increase diagnostic sensi-bility 11. If E is suspected, transvaginal ultrasound is the first diag-nostic test that should be performed, and plays an impor-tant role in many studies 5,12,13,14. Hypoechogenicendometrial nodules, and thickening of the intestinal wallcan be found in all the sites involved. Transvaginal ultra-sound performed after intestinal preparation is moreeffective in diagnosing intestinal lesions, and providesimportant details about what layers of the intestinal wallare involved and the distance between the lesion and theanal canal 13,14.Magnetic resonance imaging has high sensibility (80%)and specificity (90%) for diagnosing pelvic E, and in cas-es of extrapelvic and intraperitoneal E, is a useful adjunct

to laparoscopy. It is of key importance in identifyingendometriotic foci in extraperitoneal sites.Laparoscopy is the gold standard for diagnosing andtreating E, especially whether a biopsy is performed1.Once a definitive diagnosis has been made, resolution ofpain can be obtained with drug treatment (donazole, oralcontraceptives, aromatase inhibitors, prostaglandininhibitors, and selective progesterone antagonists),withcareful gynecological follow-up. However there are disadvantages to medical therapy: thehigh rate of recurrence if treatment is suspended, andthe costs and side effects of the drugs, and its ineffec-tiveness in treating the infertility that can be associatedwith E.Surgical therapy is the treatment of choice in patientswho no longer respond to pharmacological therapy, orhave recurrent or critical symptoms, and it is associatedwith a low rate of long-term recurrence. Moreover,surgery is necessary to avoid the malignant transforma-tion of the endometriotic foci (neoplasia-adenocarcino-ma-sarcoma ), the incidence of which has been report-ed to range from 3% to 10% 15. If there is any doubtat the time of diagnosis, an intraoperative biopsy shouldbe obtained in order to rule out neoplastic disease. Aperioperative diagnosis of E makes possible conservativesurgery, with a reduction in peri-and postoperative mor-bidity. Surgical management of patients with rectal E,continues to be a very interesting object of research anddiscussion. The procedures consist of conservative super-ficial or full thickness resection, segmental resections oreven extended debulking, but there are no random-ized/prospective studies that provide definitive results2,6,16. Before the most appropriate therapy could be selected,complete mobilization of the rectum is needed so thatthe degree of pelvic involvement could be better defined. Conservative treatment, which consists of superficial orfull-thickness resection of the lesions, is associated witha higher incidence of long-term recurrence than radicaltreatment. Multiple nodules, nodule diameter of >3 cm,the risk of strictures due to sutures, are indications forrectal resection with anastomosis 5,10,13.

Conclusions

Rectosigmoid occlusion due to E is rare, and since anemergency treatment is required, it is difficult to makea differential diagnosis of the lesion. Symptoms ofpatients with E are nonspecific. Intestinal E should beconsidered in women in childbearing age with recurrentand/or cyclical gastrointestinal symptoms, and a historyof E with gynaecological symptoms. Previous laparo-scopic and/or open surgery performed on reproductiveorgans should mark this suspicion 2,10,16.Elective treatment for colorectal E should be managedby a multidisciplinary team (gynaecologist, coloproctol-

Published online 21 Dicembre 2011 (www.annitalchir.com) - Ann. Ital. Chir., 83, 4, 2012 355

Intestinal occlusion caused by endometriosis of the sigmoid colon: a case report and review of the literature

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ogist, urologist). Conservative resection is possible in cas-es of monofocal lesions smaller than 3 cm in diameter,that are not in the subperitoneal rectum, whereas in allother cases resection followed by anastomosis may beassociated with better long-term results 3,9,14,15.

Riassunto

L’endometriosi (E) è una patologia infiammatoria estro-geno dipendente che si osserva in circa il 10% delle don-ne in età fertile e rappresenta la causa di ospedalizza-zione più frequente nell’ambito della patologia ginecolo-gica “benigna”.Nel 5% dei casi si verifica un interessamento del trattogastrointestinale per lo più del sigma-retto (~90%), tut-tavia un quadro di occlusione intestinale per stenosi ser-rata del sigma, come nel caso descritto dagli Autori, èdi rara osservazione.Nella diagnosi differenziale vanno considerati il carcino-ma, le patologie infiammatorie e la colite attinica di cuil’E ripercorre il quadro clinico. Il trattamento chirurgi-co – resezione ed anastomosi, procedure conservative –consente migliori risultati dopo un approccio multidi-sciplinare – chirurgo colorettale, ginecologo, urologo.Gli Autori, riportando un caso di occlusione intestinaleda E del sigma, analizzano le problematiche fisiopatolo-giche, diagnostiche e relative alla chirurgia.

Aknowledgement: the Authors are indebted withFrancesco Stanzione for his collaboration to the materi-al preparation of the paper.

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G. Conzo, et. al.

356 Ann. Ital. Chir., 83, 4, 2012 - Published online 21 Dicembre 2011 (www.annitalchir.com)